World Humanitarian Day is August 19th. Travelling to a third world country is what all healthcare providers should experience, as it will make a difference (to either your perspective on life and happiness or to the people who you treat). I have met some amazing people along the way, none who affect me more than those who live there (and the great way they define happiness) and those who go around the world to try to make it a better place. I have travelled to the Middle East, India, Guatemala, Honduras, Mexico, and Nepal with groups of people who have done far more than I could ever do, and the inspiration I get from them is amazing (Stanford International EM facebook page and the Rwanda PURE initiative). The stories I’ve heard, the experiences I went through, and the humbling that comes from it all are what keep me going. But, Ive realized something: there are two ways of thinking about global health and our aid efforts:
– the pessimistic (“the problem and issues in [fill in 3rd world country here] will not go away so why should I try [again]”, “I feel like I help when I go to [fill in 3rd world country here], but when I leave it’s back to where it was”, “Ive tried so hard to make things better and have gotten no where.”)
– the optimistic (“when I go to [fill in 3rd world country here] I bring lots of medical equipment, get to know the culture, and have a better understanding of the needs to make a difference in the future”, “I feel like after I leave, I’ve been able to learn from and to teach the doctors there”, “I pair up with others to incorporate a system that will help everyone get access to care which is reaching so many now when I return”)
People want to feel like they can make a difference, and that it will last and help many – I totally get it because that’s what I think. I find that it’s all in the way your goal is defined and the solution you choose. Rarely can you create a new system from scratch, but this can also happen if you have the people, resources, equipment, and funding to do it – whether that’s for preventive health, access to healthcare, treatment of epidemics/pandemics, or responding to disasters. Some things you can’t (and shouldn’t) change, but another way the effects can be felt greatly is when something that already exists gets enhanced (this is where ultrasound comes into play).
Bedside ultrasound can be an important part of many of the above issues. Several ultrasound machine companies have a global health group where you can apply for and obtain free or discounted US machines to donate to a clinic or hospital. They will also provide you loaner machines to help with your teaching. Some clinics already have the machine but don’t know how to use it. Thankfully, it’s portable, accessible, easy to learn, and easy to teach – and can continue to benefit people after you leave. Whether it’s in a disaster setting or at a village clinic with no access to radiology – it can give more information, help diagnose and manage patient disease, and help provide those limited resources to those who really need it.
In disaster settings, initially its a trauma evaluation, so the most common application used are E-FAST (for screening of injury and shock assessment), Musculoskeletal (for fracture evaluation and who needs the OR), IVC (for volume assessment in order to see who needs the limited IV bags). I also dont call it “bedside” ultrasound in disasters; I call it, instead, “patient-side” ultrasound because you don’t always have a bed. The below picture is depicts exactly that: a couple members of our group (Dr. Ian Brown and Paul Auerbach) who responded to the Haiti earthquake saw a pregnant woman who was trying to get to the care center but couldn’t, laid down on the ground, and our team came to her (bringing up the other application most commonly used in disasters – OB):
After the initial couple weeks of disaster response, the other and some chronic conditions start presenting itself. This is picture of another member of the team, Dr. Colin Bucks diagnosing appendicitis:
Procedural guidance of ultrasound also is a huge help – as Dr Jessica Ngo illustrates with this next picture:
When it comes to other global health needs (diagnosis and management of diseases affecting the third world), bedside ultrasound can be of huge assistance as well. The most common applications are E-FAST, Abdominal, OB, Echo/IVC. A few cases I’ve seen along the way that depicts this point:
An 11 year old with off an on fevers and diarrhea for over a year, now with slight jaundice and abdominal pain, visualizing the below will help in your management:
Diagnosis of above: Amoebic liver abscess
A 20 year old female with off and on rash/joint pains/chest pains over years and now with gradual onset of shortness of breath and chest pain, below is her subxiphoid view of the heart
Diagnosis of above: pericardial effusion from undiagnosed lupus
An 18year old with months of fevers and night sweats, facial /hand/leg swelling and abdominal distension with now shortness of breath. Below is his abdominal and thoracic ultrasound
Diagnosis of above: severe fluid shifting from Nephrotic syndrome from presumed TB
HIV and TB can affect many organ systems and there is no way for ultrasound to diagnose either of the two – but you can search for the sequelae of them, such as:
Lymphadenopathy, pleuritis/effusion, RUL pneumonia, glomerulosclerosis of kidney (hyperechoic bright kidney), cardiomyopathy (hypokinetic chambers), pericardial effusion….
There are amazing free online resources for global health US education for HIV and tropical diseases – an online textbook by Dr Cristoph Dietrich, and a manual for the utility of ultrasound in global health – a manual of ultrasound in resource limited settings by Dr. Sachita Shah, et al which also highlight US cases (a couple have been highlighted above).
Teaching bedside ultrasound to the healthcare providers in third world countries who have an ultrasound machine but don’t know how to use it, is an awesome experience, and definitely an example of how your visit can continue to make an affect after you leave until you return again. Below is a picture of Dr. Brita Zaia teaching doctors at the public hospital in Honduras: